Question: Palmetto, our Medicare administrative contractor (MAC) is denying ICD-10 code H53.40 Unspecified visual field defects for CPT code 92133 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve. Isn't this listed as a payable diagnosis?

Answer:

There is not one set of ICD-10 to CPT code link that is accepted by all payers. The best source is any published payer policy. Since this is Medicare, and Palmetto does not have a published policy, best practice is to obtain an advance beneficiary notice (ABN) and append modifier -GA to the appropriate level of visual field. Then the patient will receive notification that they are responsible for payment. You can also appeal the denial by showing that other MACs do cover H53.40. If possible, perhaps select a diagnosis that is more specific.

When there is no unique payer published policy, the next best source is the Coding Coach Complete Ophthalmic Coding Reference.